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ObjectiveThe goal of this article is to provide recommendations for the early career neurointerventionalist in writing a successful grant application to the National Institutes of Health (NIH) and similar funding agencies.MethodsThe authors reviewed NIH rules and regulations and also reflected on their own collective experience in writing NIH grant proposals in the area of cerebrovascular disease and neurointerventional surgery.ResultsA strong proposal should address an important scientific problem where there is a gap in knowledge. The solution offered needs to be innovative but at the same time based on a strong scientific premise. The proposed research must be feasible to implement and investigate in the researcher’s environment.ConclusionSuccessful grant writing is critical in funding and enhancing research. The information in the article may aid in the preparation stage of grant writing for early career neurointerventionalists.

BackgroundStroke systems of care employ a hub-and-spoke model, with fewer centers performing mechanical thrombectomy (MT) compared with stroke-receiving centers, where a higher number offer high-level, centralized treatment to a large number of patients.ObjectiveTo characterize rates and outcomes of readmission to index and non-index hospitals for patients with ischemic stroke who underwent MT.MethodsThis study leveraged a population-based, nationally representative sample of patients with stroke undergoing MT from the Nationwide Readmissions Database between 2010 and 2014. Descriptive, logistic regression analyses, and univariate and multivariate logistic regression models were carried out to determine patient- and hospital-level factors, mortality, complications, and subsequent readmissions associated with index and non-index hospitals' 90-day readmissions.ResultsIn the study, 2111 patients with a stroke were treated with MT, of whom 534 were readmitted within 90 days. The most common reasons for readmission were: septicemia (5.9%), atrial fibrillation (4.8%), and cerebral artery occlusion with infarct (4.8%). Among readmitted patients, 387 (74%) were readmitted to index and 136 (26%) to non-index hospitals. On multivariable logistic regression analysis, non-index hospital readmission was not independently associated with major complications (p=0.09), mortality (p=0.34), neurological complications (p=0.47), or second readmission (p=0.92).ConclusionOne-quarter of patients with a stroke treated with MT were readmitted within 90 days, and one quarter of these patients were readmitted to non-index hospitals. Readmission to a non-index hospital was not associated with mortality or increased complication rates. In a hub-and-spoke model it is important that follow-up care for a specialized procedure can be performed effectively at a vast number of non-index hospitals covering a large geographic area.

Intracerebral hemorrhage and, more specifically, intraparenchymal hemorrhage, are devastating disease processes with poor clinical outcomes. Primary injury to the brain results from initial hematoma expansion while secondary hemorrhagic injury occurs from blood-derived products such as hemoglobin, heme, iron, and coagulation factors that overwhelm the brains natural defenses. Novel neuroprotective treatments have emerged that target primary and secondary mechanisms of injury. Nonetheless, translational application of neuroprotectants from preclinical to clinical studies has yet to show beneficial clinical outcomes. This review summarizes therapeutic agents and neuroprotectants in ongoing clinical trials aimed at targeting primary and secondary mechanisms of injury after intraparenchymal hemorrhage.

BackgroundRecent surveys have failed to examine cerebrovascular aneurysm treatment practices among US physicians.ObjectiveTo survey physicians who are actively involved in the care of patients with cerebrovascular aneurysms to determine current aneurysm treatment preferences.MethodsA 25-question SurveyMonkey online survey was designed and distributed electronically to members of the Society of NeuroInterventional Surgery, Society of Vascular and Interventional Neurology, and the American Association of Neurological Surgeons/Congress of Neurological Surgeons Combined Cerebrovascular Section.Results211 physicians completed the survey. Most respondents recommend endovascular treatment as the first-line management strategy for most ruptured (78%) and unruptured (71%) aneurysms. Thirty-eight per cent of respondents indicate that they routinely treat all patients with subarachnoid hemorrhage regardless of grade. Most physicians use the International Study of Unruptured Intracranial Aneurysms data for counseling patients on natural history risk (80%); a small minority (11%) always or usually recommend treatment of anterior circulation aneurysms of ConclusionsThis survey demonstrates considerable variability in patient selection for intracranial aneurysm treatment, preferred treatment strategies, and follow-up imaging schedules among US physicians.

BackgroundBurnout takes a heavy toll on healthcare providers. We sought to assess the prevalence and risk factors for burnout among neurointerventional (NI) non-physician procedural staff (nurses and technologists) given increasing thrombectomy demands.MethodsA 41-question online survey containing questions including the Maslach Burnout Inventory-Human Services Survey for Medical Personnel was distributed to NI nurses and radiology technologists at 20 US endovascular capable stroke centers.Results244 responses were received (64% response rate). Median (IQR) composite scores for emotional exhaustion were 25 (15–35), depersonalization 6 (2–11), and personal accomplishment 39 (35–43). Fifty-one percent of respondents met established criteria for burnout. There was no significant relationship between hospital thrombectomy volume, call frequency, call cases covered, or length of commute. On multiple logistic regression analysis, feeling under-appreciated by hospital leadership (OR 4.1; PConclusionsThis survey of US NI non-physician procedural staff demonstrates a self-reported burnout prevalence of 51%. This was driven more by interaction with leadership and physician staff than by thrombectomy procedural volume and stroke call. Attrition among NI non-physician procedural staff is high.

Over the past decade there has been a growing use of intracranial stents for the treatment of both ischemic and hemorrhagic cerebrovascular disease, including stents to assist in the remodeling of the neck of aneurysms as well as the use of flow diverting devices for aneurysm treatment. With this increase in stent usage has come a growing need for the neurointerventional (NI) community to understand the pharmacology of medications used for modifying platelet function, as well as the testing methodologies available. Platelet function testing in NI procedures remains controversial. While pre-procedural antiplatelet assays might lead to a reduced rate of thromboembolic complications, little evidence exists to support this as a standard of care practice. Despite the routine use of dual antiplatelet therapy (DAT) with aspirin and a P2Y12 receptor antagonist (such as clopidogrel, prasugrel, or ticagrelor) in most neuroembolization procedures necessitating intraluminal reconstruction devices, thromboembolic complications are still encountered.1–3 Moreover, DAT carries the risk of hemorrhagic complications, with intracerebral hemorrhage (ICH) being the most potentially devastating.4 ,5 Light transmission aggregometry (LTA) is the gold standard to test for platelet reactivity, but it is usually expensive and may not be easily obtainable at many centers. This has led to the development of point-of-care assays, such as the VerifyNow (Accumetrics, San Diego, California, USA), which correlates strongly with LTA and can reliably measure the degree of P2Y12 receptor inhibition.6–9 VerifyNow results are reported in P2Y12 reaction units (PRUs), with a lower PRU value corresponding to a higher level of P2Y12 receptor inhibition and, presumably, a lower probability of platelet aggregation, and a higher PRU value corresponding to a lower level of P2Y12 receptor inhibition and, hence, a higher chance of platelet activation and aggregation. While aspirin resistance is perhaps less common, clopidogrel resistance may be more challenging as …

Background We previously performed a multicenter prospective single-arm trial of 100 patients treated with Axium MicroFX Coils (ev3; Plymouth, Minnesota, USA), AMERICA: Axium MicroFX for Endovascular Repair of IntraCranial Aneurysm study. Initial angiographic and clinical outcomes were excellent. The final results are presented herein. Methods AMERICA is a multicenter, prospective single-arm trial evaluating the safety and efficacy of the ev3 Axium MicroFX coil system in 100 separate aneurysms between April 2010 and October 2012. Trial endpoints were 3–6 month angiographic occlusion and clinical status, as reported by treatment center. Results Mean follow-up was 157.9 days (median 153.5, range 1–445, SEM 9.3 days). At last follow-up imaging, 90.6% of all aneurysms, 90% of unruptured aneurysms, and 93.3% of ruptured aneurysms had Raymond grade I or II occlusion. Progression to further occlusion (lower Raymond occlusion grade) occurred in 29/85 aneurysms (34.1%). Aneurysm recurrence occurred in 11/85 aneurysms (12.9%). Ninety-nine per cent of patients treated electively and 68.7% of ruptured patients had a modified Rankin score of 0–2. Delayed adverse events (AEs), occurring after discharge and during the follow-up period, occurred in 10% of patients. In total, two AEs (one severe and one moderate) were potentially related to the device, thereby providing a 2% device-related AE rate. Conclusions In this prospective, multicenter series of 100 aneurysms treated with Axium MicroFX PGLA (polyglycolic/polylactic acid) coils, 3–6 month angiographic occlusion and clinical outcomes were excellent. This study suggests that Axium MicroFX PGLA coils are safe and effective in the treatment of intracranial aneurysms.

We read with interest the comments by Leira and Savitz1 in the June 2018 issue of Stroke regarding ischemic stroke triage, administration of intravenous tissue plasminogen activator (IV tPA), and mechanical thrombectomy. Although the topic is timely and the authors’ insights clearly expressed, we disagree with both the concluding statements and the supporting arguments that lead to these inferences. Current evidence does not suggest that advances in mechanical thrombectomy are occurring at the expense of IV tPA only treated patients, and primary stroke centers (PSCs) are not at an existential risk. We offer the following thoughts: Endovascular therapy (ET) is now the standard of care for emergent large vessel occlusion (ELVO) acute ischemic stroke following the overwhelmingly positive outcomes from multiple randomized trials that compared ET with IV tPA or best medical management.2–8 It is one of the most effective therapies available in modern medicine.2–8 It was estimated that only 10–15% of patients with acute ischemic stroke were eligible for ET.9–11 In the past year, the number of eligible patients has increased further due to the demonstrated efficacy of treatment for …

Vertebroplasty and kyphoplasty are minimally invasive image-guided procedures that involve the injection of cement (typically polymethylmethacrylate (PMMA)) into a vertebral body. Kyphoplasty involves inflation of a balloon tamp to create a cavity within the vertebral body into which cement is subsequently injected. The majority of these vertebral augmentation procedures are performed to relieve back pain from osteoporotic or cancer-related vertebral compression fractures and to reinforce the vertebral body with neoplasm or vascular tumor. The primary goal of vertebroplasty and kyphoplasty is to reduce back pain and to improve patient's functional status, and the secondary goal is stabilization of a vertebra weakened by fracture or neoplasia. ### Osteoporotic vertebral fractures Osteoporosis is a common disease that causes significant morbidity and incurs a significant healthcare cost to the community. The major osteoporotic fractures involve the hip, vertebra, proximal humerus and distal forearm; the lifetime osteoporotic fracture risk at age 50 is approximately one in two women and one in five men.1 The lifetime incidence of symptomatic osteoporotic vertebral fractures in women at age 50 is estimated at 10–15%1; once a vertebral fracture occurs, there is a 20% risk of another vertebral fracture within 12 months.2 Most osteoporotic vertebral compression fractures are asymptomatic or result in minimal pain; only a third of vertebral fractures result in medical attention.3 Conservative medical therapy is therefore appropriate for the vast majority of vertebral compression fractures since most acute back pain symptoms are mild and subside over a period of 6–8 weeks as the fracture heals. The goals of conservative therapy are pain reduction (with analgesics and/or bed rest), improvement in functional status (with orthotic devices and physical therapy) and prevention of future fractures (with vitamin D, calcium supplementation and antiresorptive agents). However, conservative treatment for those with severe pain or limitation of function is not benign. It …

Axium MicroFX coils contain polymer (polyglycolic/polylactic acid, PGLA) microfilaments designed to significantly impact intra-aneurysmal flow and to encourage aneurysm thrombosis. To provide preliminary evaluation of the safety and suggested efficacy of the MicroFX design, we performed a multicenter prospective single-arm trial, Axium MicroFX for Endovascular Repair of IntraCranial Aneurysm study (AMERICA).AMERICA is a prospective multicenter 100 aneurysm observational study evaluating the safety and efficacy of Axium MicroFX PGLA coils. Enrollment was started in April 2010 and completed in October 2012.99 patients underwent treatment for 100 aneurysms at 13 centers. Mean age was 60.2 years, most were women (72%) and 18% of patients had previously undergone treatment for a separate aneurysm. 22% of patients underwent treatment after acute aneurysmal subarachnoid hemorrhage (SAH). Of these patients, all were Hunt and Hess grade 1-3. Pre-procedure modified Rankin score (mRS) was 0-2 in 92% of patients. The majority of aneurysms were anterior circulation (86%), with the most common aneurysm locations being the anterior communicating artery (23%) followed by the supraclinoid internal carotid artery and posterior communicating artery (18% each). The mean maximum diameter was 6.5 mm. Axium MicroFX coils could be placed in all but one treatment (99%). Raymond grade at conclusion of coiling was I (complete) in 52%, II (dog ear or residual neck) in 33% and III (residual aneurysm) in 15%. Discharge mRS was significantly worse in patients with SAH (62% mRS 0-2) compared with electively treated aneurysms (mRS 0-2 in 94%, p001). Major events were uncommon (6% thromboembolic events, 3% intraoperative vessel or aneurysm rupture) and device-related adverse events (AE) were rare (2% of cases).This prospective study of Axium MicroFX coils demonstrates excellent aneurysm occlusion rates. 52% of aneurysms were completely occluded post-procedure. Within the ruptured aneurysm group, post-procedure occlusion rates were 63.6%. Major AE rates were consistent with historical data.

Mechanical thrombectomy for the treatment of emergent large vessel occlusion has entirely transformed neuroendovascular surgery and acute stroke care delivery over the past 10 years. The procedure has led to an unparalleled fundamental change in stroke management and treatment. From the controversial acute endovascular stroke trials of 20131–3 to the overwhelmingly positive 2015 trials,4–8 the topic has dominated international scientific conferences, the pages of our most prestigious journals, and everyday conversations among practitioners across a wide variety of specialties. As mechanical thrombectomy is now widely accepted as the standard of care …

The success of the 2015 stroke trials changed the indications for mechanical thrombectomy and the landscape of acute stroke care.1–5 A treatment we have always believed to be beneficial was shown, without doubt, to be effective. Systems of care have been designed around IA therapy for acute stroke. Procedural volumes have increased dramatically. Most importantly, a large number of patients have directly benefitted from this procedure. The 2015 mechanical thrombectomy studies succeeded for many reasons. The trials were thoughtful and well designed. The operators were experienced. Recanalization rates have now improved drastically. Thrombolysis in Cerebral Infarction 2b or 3 is now the expectation, and short procedural times the norm. Regardless of specific recanalization methods, we, as a field, have become very good at opening occluded blood vessels quickly. There remains room for improvement, but the margin is decreasing. Device development and procedural adaptations have been the bell cow thus far; tools have evolved from the Merci device to aspiration and stentrievers. Balloon guide catheters and direct carotid access have played a role. We have all recognized that we need to …

A first year medical student recently contacted me because he was interested in “pursuing a career in neuroendovascular surgery and wanted to learn more about the field”. I was, at first, impressed that a first year medical student even knew that a specialty called neuroendovascular surgery existed. When I entered medical school I am quite certain I had never heard of neuroendovascular surgery, interventional neuroradiology, endovascular neurosurgery, or endovascular neurology. In preparation for a meeting with this precocious medical student, I began to think about how to explain and describe the field of neuroendovascular surgery. It's fairly complicated. Ours is a field composed of multiple specialties that treats many diverse disease processes. Most of our procedures are performed through the blood vessels, but not all. At one time it could be said that all of our procedures were performed in the angiography suite. With the advent of hybrid operating rooms and an extension of our technology into other fields, this is no longer even the case. What I realized is that a sizeable appeal of our specialty is the diversity of the cases and the ability to …

In the current issue of the journal, a study by Sheth et al 1 has examined the safety and efficacy of thrombectomy for acute ischemic stroke (AIS) using the Solitaire stent retriever device for patients treated in the roll-in phase of the Solitaire With the Intention For Thrombectomy (SWIFT) trial. This is a well designed study aimed at determining the learning curve for operators who had not previously used Solitaire for the treatment of emergent large vessel occlusion (ELVO). The roll-in period entailed treatment of two patients with the Solitaire device, before proceeding to the randomized phase of the trial. This represented the first clinical use of the stent retriever for these operators. Compared with randomized patients, those treated with Solitaire in the roll-in period achieved equivalent rates of reperfusion (55% vs 61%), adverse events (13% vs 9%), and good neurological outcomes (63% …

Just 2 years ago, at the International Stroke Conference in Honolulu, Hawaii, USA, the Interventional Management of Stroke (IMS III),1 Mechanical Retrieval and Recanalization of Stroke Clots Using Embolectomy (MR RESCUE),2 and SYNTHESIS-Expansion3 trials were presented and concurrently published in The New England Journal of Medicine. The overarching message to the medical community and lay press was that these studies provided unambiguous evidence that mechanical thrombectomy was ineffective in treating acute stroke secondary to emergent large vessel occlusion (ELVO). The investigators were careful to emphasize the adaptive designs of their trials, which allowed sites to use new thrombectomy devices as technology evolved, thus implying that the results would be directly applicable to modern clinical practice. When scrutinized by the interventional community, however, it was clear that these three trials had significant shortcomings.4 ,5 Most notably, these trials were limited by the predominant use of antiquated thrombectomy technologies, poor revascularization rates, and the lack of vascular imaging required for patient enrollment. Collectively, these shortcomings made the studies’ conclusions largely irrelevant to the contemporary application of thrombectomy for ELVO. Unfortunately, this highly technical and nuanced argument was buried by the mantra: “thrombectomy shown to be ineffective in three clinical trials”, an easily understood and succinct message. …

Objectives To determine the accuracy of coding of admissions for stroke on weekdays versus weekends and any impact on apparent outcome. Design Prospective population based stroke incidence study and a scoping review of previous studies of weekend effects in stroke. Setting Primary and secondary care of all individuals registered with nine general practices in Oxfordshire, United Kingdom (OXVASC, the Oxford Vascular Study). Participants All patients with clinically confirmed acute stroke in OXVASC identified with multiple overlapping methods of ascertainment in 2002-14 versus all acute stroke admissions identified by hospital diagnostic and mortality coding alone during the same period. Main outcomes measures Accuracy of administrative coding data for all patients with confirmed stroke admitted to hospital in OXVASC. Difference between rates of “false positive” or “false negative” coding for weekday and weekend admissions. Impact of inaccurate coding on apparent case fatality at 30 days in weekday versus weekend admissions. Weekend effects on outcomes in patients with confirmed stroke admitted to hospital in OXVASC and impacts of other potential biases compared with those in the scoping review. Results Among 92 728 study population, 2373 episodes of acute stroke were ascertained in OXVASC, of which 826 (34.8%) mainly minor events were managed without hospital admission, 60 (2.5%) occurred out of the area or abroad, and 195 (8.2%) occurred in hospital during an admission for a different reason. Of 1292 local hospital admissions for acute stroke, 973 (75.3%) were correctly identified by administrative coding. There was no bias in distribution of weekend versus weekday admission of the 319 strokes missed by coding. Of 1693 admissions for stroke identified by coding, 1055 (62.3%) were confirmed to be acute strokes after case adjudication. Among the 638 false positive coded cases, patients were more likely to be admitted on weekdays than at weekends (536 (41.0%) v 102 (26.5%); P

The recent completion of the MR CLEAN trial1 and news of early stoppage of other stroke trials demonstrates the ability for the neurointerventional community to address a crucial question that has hindered the ability of intra-arterial therapy (IAT) to be offered more widely. The focus of future studies will now shift towards improving clinical outcomes in patients undergoing IAT. ### Imaging There is currently no consensus regarding the optimal imaging strategy for the selection of patients for intervention. The modality must be efficient, accurate, available and repeatable. Non-contrast CT using Alberta Stroke Program Early CT Score (ASPECTS) scoring,2 CT perfusion and MRI are all in widespread clinical usage at interventional stroke centers. A trial comparing different modes of imaging based patient selection would be valuable and currently does not exist. There are advantages and disadvantages to each technique with strong beliefs that each modality has its advantages. The question is whether the widespread availability, ease of access and time savings justify using non-contrast CT (supplemented by ASPECTS) as ‘good enough’ to select patients when compared to advanced imaging modalities that may be more specific to detecting ischemia. Developing an educational pathway with ASPECTS scoring to reduce inter-rater variability along with a standardized CT perfusion algorithm that can be replicated across institutions can allow for a trial examining this question to occur. The current landscape would potentially also allow for an MRI comparative trial. One starting point might be a core-lab adjudicated, prospective registry comparing pre- and post-treatment ASPECTS, computed tomography perfusion (CTP) and/or MRI data from …

Objective To evaluate the association between weekend admission to hospital and 11 hospital acquired conditions recently considered by the Centers for Medicare and Medicaid as “never events” for which resulting healthcare costs are not reimbursed. Design National analysis. Setting US Nationwide Inpatient Sample discharge database. Participants 351 million patients discharged from US hospitals, 2002-10. Main outcome measures Univariate rates and multivariable likelihood of hospital acquired conditions among patients admitted on weekdays versus weekends, as well as the impacts of these events on prolonged length of stay and total inpatient charges. Results From 2002 to 2010, 351 170 803 patients were admitted to hospital, with 19% admitted on a weekend. Hospital acquired conditions occurred at an overall frequency of 4.1% (5.7% among weekend admissions versus 3.7% among weekday admissions). Adjusting for patient and hospital cofactors the probability of having one or more hospital acquired conditions was more than 20% higher in weekend admissions compared with weekday admissions (odds ratio 1.25, 95% confidence interval 1.24 to 1.26, P